197602851-8-31-2023-28-AS-AGOZ-CV97RX-20230831215417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602851
Report Date: 08/31/2023
Date Signed: 08/31/2023 09:54:22 PM

Document Has Been Signed on 08/31/2023 09:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GENESEE VILLA		FACILITY NUMBER:	197602851
ADMINISTRATOR:	MARIA CLARK		FACILITY TYPE:	740
ADDRESS:	1441 GENESEE		TELEPHONE:	(323) 935-2244
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	6	CENSUS: 6	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Clark		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with Administrator Maria Clark and explained the purpose for the visit. The facility is licensed to serve 6 ambulatory and 1 non-ambulatory elderly residents age 59 and over. Currently, there are six (6) residents placement. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs (SHN). During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. There is a visitor sign-in/ screening station located in the main entrance. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator six (6) residents have COVID-19 vaccines including boosters. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements. Refer to LIC 809C for continuation of report

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GENESEE VILLA	FACILITY NUMBER: 197602851
	VISIT DATE: 08/31/2023

NARRATIVE

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Operational Requirements: Fire Drills are conducted every three months, the last fire drill was conducted on 6/14/23. Emergency Disaster/ Earthquake Drills are also conducted every six months and the last one was conducted on 6/14/23. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The home is located in a residential area, the facility is a two story facility which consists of: living room, kitchen with dining area, office, detached laundry room, five (5) bedrooms, three (3) bathrooms. All resident rooms were checked. All resident beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Bathrooms are clean, sanitary and operational with grab bars and non skid mats in place. Water temperature properly measured at 120F*. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front yard is free of debris and/or hazards. A shaded area with chairs is provided for residents in the front porch of the facility

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator certificate expiration date 4/11/2024.

Refer to LIC 809C for continuation of report

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GENESEE VILLA	FACILITY NUMBER: 197602851
	VISIT DATE: 08/31/2023

NARRATIVE

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Resident Records-Incident Reports: LPA reviewed Client files for R1 through R3. Resident files are maintained at the facility and have the following documents in their files: Admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment/Appraisals, and emergency information.

Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician order for modified diet is on file. Sanitation practices and kitchen cleanliness was observed.

Incidental Medical Services: Three (3) centrally stored 30-day supply of medications were reviewed. Medical and dental transportation is provided by facility and family members.

Disaster Preparedness: Emergency and Disaster Plan LIC 610D is in place. The last fire/emergency drill was completed on 6/14/2023.

Residents with SHN : There are no residents that receive hospice care. Appraisals were observed in resident files. No residents have prohibited health conditions.

No deficiencies noted. Exit interview and a copy of this report was provided to Administrator Maria Clark.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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